Gastroenterology Coding Alert

Effective July 1, 2001, HCFA will extend the benefit of a screening colonoscopy to Medicare patients not at high risk (also known as average risk) for developing colorectal cancer. In a transmittal dated Feb. 8, 2001, the agency stated that HCPCS code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) should be used to report the new benefit, and that the payment for all screening colonoscopies should be the same as the payment for a diagnostic colonoscopy (45378).

The policy is good medical care and is in keeping with the results of studies showing the effectiveness of colonoscopy in decreasing colorectal cancer death and colonoscopys superiority over all other screening tests, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT Advisory Panel. During the past few years it was difficult to explain to a patient that the screening colonoscopy advised by his or her primary care physician was not covered by Medicare. The complete colorectal cancer screening policy that is effective July 1, 2001, (with changes in boldface) is as follows:

Screening fecal-occult blood tests (G0107) for beneficiaries who have attained age 50, and at a frequency of once every 12 months.

Screening flexible sigmoidoscopies (G0104) for beneficiaries who have attained age 50 at a frequency of once every 48 months.

Screening colonoscopies (G0105) for beneficiaries at high risk for developing colorectal cancer at a frequency of once every 24 months.

Screening colonoscopies (G0121) for beneficiaries not meeting the criteria of high risk at a frequency of once every 10 years. (Note: Prior to July 1, 2001, this code is used to report noncovered screening colonoscopies on Medicare beneficiaries who did not meet the criteria of high risk.)

Screening barium enema examinations (G0106 and G0120) are covered as an alternative to either a screening sigmoidoscopy (G0104) or a screening colonoscopy (G0105). Note: If its a substitute for a G0104, use the G0104 frequency parameter of once every 48 months. If its a substitute for a G0105, use the frequency parameter of once every 24 months.

Problems with High-risk Criteria

Ever since the original colorectal cancer screening policy was established as part of the Balanced Budget Act of 1997, gastroenterologists have disliked the screening colonoscopy benefit. One of the problems was defining who was high risk. HCFAs national policy states that the following diagnosis codes meet the high-risk criteria:

V10.05 personal history of malignant neoplasm of large intestine
V10.06 personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
555.0 regional enteritis of small intestine
555.1 regional enteritis of large intestine
555.2 regional enteritis of small intestine with large intestine
555.9 regional enteritis of unspecified site
556.0 ulcerative (chronic) enterocolitis
556.1 ulcerative (chronic) ileocolitis
556.2 ulcerative (chronic) proctitis
556.3 ulcerative (chronic) proctosigmoiditis
556.8 other ulcerative colitis
556.9 ulcerative colitis, unspecified
558.2 toxic gastroenteritis and colitis
558.9 other and unspecified noninfectious gastroenteritis and colitis

This list, however, excludes many diagnoses that primary care physicians and gastroenterologists consider to be high-risk indicators, such as family history of colorectal cancer (V16.0) and family history of other digestive disorders (V18.5). While many carriers have added these two diagnoses to their list of covered diagnosis codes for G0105 screening colonoscopies, others have not.

Also, many Medicare patients who did not meet the high-risk criteria were nevertheless requesting screening colonoscopies from their gastroenterologists. Recent literature [in the New England Journal of Medicine and other medical journals] has shown that colonoscopy is effective in decreasing mortality from colon cancer. Flexible sigmoidoscopy [another benefit to average-risk Medicare patients] is also effective but misses growths in the right colon, Weinstein explains. There are some individuals in the public, such as Today show host Katie Couric, who have advocated an average-risk screening colonoscopy beginning at age 40.

Follow G0121 Frequency Parameters

While this new benefit offers gastroenterologists payment for another tool in the prevention of colorectal cancer, they must be aware of the frequency parameters that HCFA has set for the G0121 colonoscopy. It can be performed once every 10 years (i.e., at least 119 months have to pass following the month in which the last covered G0121 screening colonoscopy was performed). If a Medicare patient receives a G0121 colonoscopy in August 2001, for example, the count starts with September 2001. The patient is eligible for another G0121 colonoscopy in August 2011.

The newly revised Medicare Carriers Manual section 4180.2(D) states, If the patient would otherwise qualify to have a covered G0121 screening colonoscopy performed but has had a covered screening flexible sigmoidoscopy [G0104], then he or she may have a covered G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed. If the patient has had a screening flexible sigmoidoscopy within the past four years, then he or she will have to wait the entire four-year period for the screening flexible sigmoidoscopy to pass before he or she can have a G0121 colonoscopy.

Also, patients who have a G0121 colonoscopy cannot subsequently have a screening flexible sigmoidoscopy (G0104) until 119 months have passed following the month of the initial G0121 colonoscopy procedure.

ABN Is Recommended

Because a carrier may deny the claim if these frequency periods are not met, gastroenterologists should ask beneficiaries about any endoscopies they may have received when the medical history is being reviewed. Also, each patient should sign an advanced beneficiary notice (ABN). This notice should include language about the 10-year frequency period between screenings and inform the patient that he or she must pay for the procedure if Medicare does not cover it because the allowable frequency period has been exceeded.

Patients will not necessarily provide correct information about prior exams and/or the dates of prior exams by other physicians. Medicare will still deny the screening even retroactively if they find that the patient had a previous screening exam within the defined time periods, Weinstein explains.

Use V76.51 For Diagnosis Code

HCFA has not indicated what diagnosis code should be used when reporting the new benefit. V76.51 (special screening for malignant neoplasms, colon) is an appropriate code to report with G0121, says Kathy Pride, CPC, coding supervisor for Martin Memorial Medical Group, a multi-specialty practice with two gastroenterologists in Stuart, Fla. We use V76.51 with the G0121 screening colonoscopy, and V76.41 (special screening for malignant neoplasms, rectum) for the G0107 fecal-occult blood tests. But a colonoscopy goes up much higher into the colon, so you should be using a different diagnosis code.

Pride notes, however, that the carriers are free to require a different diagnosis code and recommends gastroenterologists look for announcements in their carriers Medicare bulletin or revised local medical review policies that state the specific diagnosis codes that are acceptable.

As with the G0105 colonoscopy, if a lesion or growth is detected during a G0121 colonoscopy and results in a biopsy or removal, the appropriate diagnostic colonoscopy code should be reported.

Finally, a brief note on the facilities-reimbursement side: HCFA has not formally announced that G0121 is on the approved procedure list for ambulatory surgery centers (ASCs). That announcement is expected before the July 1 effective date, and Gastroenterology Coding Alert will report it.